Nneka Catherine Mormah, registration number 2237158, has been warned by the General Pharmaceutical Council (GPhC) after incorrectly dispensing a high-risk, prescription-only immunosuppressant that \u201ccontributed\u201d to a patient\u2019s death.<\/p>\n
On October 12, the GPhC\u2019s investigating committee said a coroner\u2019s inquest found that the 88-year-old patient died of natural causes \u201ccontributed to by an error by the pharmacy\u201d concerning the \u201cdose and quantity of the medication\u201d.<\/p>\n
The determination document<\/a> said Mormah was the locum responsible pharmacist, assisted by a dispenser, on January 17, 2025, when she dispensed 98 tablets of methotrexate rather than the prescribed 14 tablets.<\/p>\n Read more: Responsible pharmacist warned over CD failures at Well pharmacy<\/a><\/p>\n It said the patient\u2019s handwritten prescription from a dermatologist was for methotrexate to be taken weekly on Mondays as an incremental dose, as well as folic acid on Fridays, but the weekly dose was \u201cerroneously dispensed to be taken daily\u201d.<\/p>\n And it noted that the error was not identified \u201cat the point of calculation, dispensing or the final accuracy check\u201d and the methotrexate was subsequently dispensed to the patient.<\/p>\n \u201cExtensive skin damage\u201d<\/p>\n The GPhC said the patient attended the emergency department on January 31 with \u201craw and ulcerated skin that was bleeding\u201d, and was treated for \u201cextensive skin damage secondary to overdosing on methotrexate\u201d. <\/p>\n He was in \u201csignificant discomfort\u201d from skin inflammation and mouth ulcers, it added. <\/p>\n The regulator said arrangements were made on February 3 to admit the patient to the intensive care unit after he \u201cwas found to have stopped breathing\u201d, but as the patient did not wish for CPR to be attempted, he was \u201cpronounced dead\u201d.<\/p>\n Read more: Superintendent warned for weight loss drugs to anorexia patient<\/a><\/p>\n The GPhC\u2019s investigating committee said methotrexate was \u201ca factor in his death\u201d, with the coroner\u2019s inquest finding that the dose and quantity dispensed to him had \u201ccontributed\u201d.<\/p>\n The patient had taken 65mg of methotrexate over an 11-day period, rather than the intended 12.5mg, it said.<\/p>\n \u201cInadequate\u201d checks<\/p>\n The committee said issuing 98 tablets to an elderly patient who was \u201cnot stable on treatment\u201d was \u201chighly unusual\u201d and \u201cis likely to have presented a risk of harm\u201d.<\/p>\n It added that Mormah did not \u201cconsider the length of treatment\u201d, question the quantity prescribed or \u201cmonitoring\u201d with the patient and prescriber, and said the prescriber \u201cshould have been contacted prior to dispensing\u201d.<\/p>\n It said \u201crigorous monitoring and counselling are required\u201d for the prescription of methotrexate, as well as checking the patient understands the instructions, but this \u201cwas not done\u201d. <\/p>\n Read more: Pharmacist warned for dispensing without identity verification<\/a><\/p>\n And it noted that counselling on the safe use of the drug should have clarified which day of the week to take it, \u201cwhich would have identified it as a weekly dose\u201d.<\/p>\n The patient medication record system ProScript also \u201calerted the pharmacy team\u201d to the weekly prescription of methotrexate and the need for \u201cregular monitoring and blood tests\u201d, and it \u201crequired acknowledgement prior to dispensing\u201d that the medication should only be dispensed weekly and of its \u201chigh-risk nature\u201d.<\/p>\n The committee said the clinical check \u201cdoes not simply involve issuing the quantity prescribed\u201d, adding that \u201cno discussion took place with the prescriber or patient\u201d about issuing 98 tablets.<\/p>\n Read more: Warning over unsafe Mounjaro prescribing at unregulated clinic<\/a><\/p>\n It highlighted that methotrexate should be used \u201cwith extreme caution in elderly patients\u201d and that patients should be reminded of the once-weekly dosing because of the \u201crisks of [a] potentially fatal overdose\u201d if they take more than they should.<\/p>\n The committee also said the checking process was \u201cinadequate\u201d, with folic acid being prescribed weekly on the same prescription when it is recommended to be taken on a different day to the methotrexate dose.<\/p>\n And it noted that Mormah did not check if the patient had an alert card or methotrexate booklet when dispensing the prescription, \u201cdespite it being good practice\u201d.<\/p>\n \u201cNot be repeated\u201d<\/p>\n The committee said Mormah \u201cpotentially breached\u201d three GPhC standards and warned her that \u201csuch conduct must not be repeated\u201d.<\/p>\n It reminded her that she must meet the statutory obligations of a responsible pharmacist or superintendent pharmacist \u201cat all times\u201d, and that any repetition of \u201cthis or similar conduct will likely result in further regulatory intervention\u201d.<\/p>\n